Embedding sustainability into clinical medicine and medical education

Why it should and how it can be done

How one healthcare body is introducing education on
sustainable healthcare across the sector.

Environmental change is an increasingly important determinant
of health and of the ability of societies and healthcare services to respond to
ill health. Climate change has been recognised as the “biggest global health
threat of the 21st Century” (Costello et al. 2009). Its effects on health are
predicted to be overwhelmingly negative, impacting on the social and
environmental determinants of health (World Health Organization, 2017).
Healthcare professionals have a duty to protect health and can do this by
focusing on the four principles of sustainable clinical care: prevention,
patient empowerment and self care, lean systems and low carbon alternatives.

Furthermore, there is an imperative and a legal duty to
reduce waste and resource use, in particular carbon emissions. The NHS is
committed to reducing its greenhouse gas emissions by 80% on 1990 levels by
2050 (UK Parliament, 2008). In addition to this, environmental, social and
financial resource constraints risk impacting on the quality of healthcare
services. Recognising this, the Royal College of Physicians has identified
sustainability as a domain of quality (Royal College of Physicians, 2011).
Doctors need to be equipped to lead the delivery of a sustainable health
service.

It is imperative that future doctors are capable of meeting
these challenges and medical education is central to a sustainable future for
healthcare. Current areas of focus such as public health and health
inequalities, quality improvement, medical leadership and ethics can usefully
be approached through the lens of sustainability.

Embedding sustainability into clinical care.

Embedding environmental sustainability into the health
sector has been the goal of the Centre of Sustainable Healthcare (CSH ) since
2008, when it was established. NHS estates were originally the main focus of efforts
to improve sustainability however this approach was reassessed when research on
the carbon footprint of the NHS found that clinical services were responsible
for the majority of greenhouse gas emissions (Sustainable Development Unit,
2008).

As a means to address this CSH developed a particular focus
on engaging clinicians and promoting the concept of sustainable clinical
practice. It has done this by setting up a sustainable specialties programme,
developing a Sustainable Quality Improvement methodology and working with
hospital Trusts on sustainability projects.

The Sustainable Specialties programme fosters change within
clinical communities. It does this by supporting clinicians to learn about
sustainability, promote and teach about it, evaluate their specialty and
determine where sustainable changes can be made (in postgraduate colleges, at a
commissioning and policy level or on the ground with colleagues and patients)
and get involved in innovating themselves. This approach was originally and successfully
demonstrated in kidney care in 2009-11 when CSH established a Green Nephrology
Fellowship. The fellows developed a Network of local sustainability
representatives in more than 80% of UK kidney units. They also worked on a
programme of research, annual awards and practical initiatives developed within
renal medicine. Following this, in 2013, The Royal College of Psychiatrists
became the first medical Royal College to fund a Sustainable Specialty Research
Fellowship. The fellow was responsible for organising a Sustainability in
Psychiatry Summit and the launch of an RCPsych Sustainability Award. Focussing
on policy and commissioning he produced a report for the Academy of Medical
Royal Colleges (Maughan and Ansell, 2014) and a guide to sustainable commissioning
(Joint Commissioning Panel for Mental Health & Centre for Sustainable
Healthcare, 2015).

As this approach has evidenced, enabling clinicians to make
change from within their own specialties has the potential to have a
significant impact on clinical care. CSH has therefore developed scholarship
programmes within other specialties. CSH training on sustainability, mentoring,
resources (including carbon footprinting), advisory groups and networks have
all helped support the fellows and scholars in their efforts and have been a
fundamental part of embedding sustainability into clinical practice. Specialty
networks have been an invaluable tool in promoting sustainability and
transformative models of care but also to provide support to those endeavouring
to make sustainable change. They help avoid duplication of work and bring a
wealth of knowledge and advice to all those engaged in sustainability
networks.sustainablehealthcare.org.uk.

Other tools also help provide clinicians with a framework to
make sustainable change. One of these tools is a Sustainable Quality
Improvement (SusQI) methodology. Increasingly clinicians are being expected to
get involved with quality improvement projects. Understanding how to study,
plan and execute changes to healthcare pathways that involve not only
improvements in health outcomes and reductions in financial costs (as in
traditional quality improvement) but also reduce environmental and social costs
as well can be difficult. The SusQI method provides a clear way to do this and
has been used effectively by clinicians to develop and subsequently evaluate
work to improve the quality of healthcare.

Along with its project and research work with CCG’s,
industry and other bodies (e.g. carbon foot printing a service, comparing the
sustainability of different care pathways, supporting the expansion of inhaler
recycling) CSH also works with hospital Trusts to run the Green Ward
Competition. This is a clinical engagement programme where clinical teams are
recruited to compete against one another and are supported by CSH to develop
sustainability projects and measure environmental, financial and patient/staff
benefits. This alternative method of working with clinicians in a clinical
setting has proved popular and successful leading to cost and carbon savings as
well as patient benefits (Centre for Sustainable Healthcare, 2017).

Embedding sustainability in clinical care is not just about
making change inside the clinic setting but also outside. Acknowledging that
green spaces are part of the tapestry of promoting and sustaining health, CSH
’s NHS Forest project has worked with healthcare organisations to value their
green spaces and promote better use of the natural environment by staff,
patients and local communities.

Through these mechanisms above it has been possible to raise
the profile of sustainability within clinical medicine and to make sustainable
change. Using this approach has ensured that changes have been driven by those
who know the system best and have not been imposed from above.

Embedding sustainability into medical education

Sustainability is gradually being embedded into medical
education. CSH has facilitated this by hosting the Sustainable Healthcare
Education (SHE ) Network. This is a network of students and educators
interested in preparing health professionals to build and work in a sustainable
health service. The network has been instrumental in driving sustainable change
within medical education. In September 2011 the General Medical Council asked
the SHE Network to make recommendations for priority learning outcomes for
sustainability, to inform the on-going development of undergraduate and
postgraduate medical curricula. The resulting priority learning outcomes have
been referenced in the GMC’s outcomes for graduates' (General Medical Council,
2015).

Since then the SHE network has continued to work in medical
education nationally and internationally researching, teaching and promoting
sustainability. Members of the SHE Network have worked with UK medical schools
to develop courses on sustainability (Walpole and Mortimer, 2017) and a bank of
case studies and teaching materials is being collated.

The SHE Network aims not only to support effective teaching,
learning and assessment for sustainable healthcare literacy but also to effect
change in curricula and work further with regulatory bodies to bring
sustainable healthcare into mainstream teaching. Embedding sustainability into
clinical care and medical education requires a multifaceted approach that
utilises the ability, knowledge and networks of those working in healthcare and
healthcare education, supported by a framework of resources, methodology and
research. Regulatory bodies, guideline, research, standards and reference
organisations as well as providers, commissioners, industry and other health
groups have all been engaged in the approach that CSH has taken, focussing on
the power of individuals and networks to drive improvement and a more
sustainable way of working.

Key Points

There are important legal, ethical and public health reasons
to embed sustainability into clinical care and medical education

Clinicians can effectively drive sustainable change from
within their specialty

Networks are essential to support and promote sustainability

Sustainable healthcare education is fundamental to a
sustainable future